In the healthcare industry, there are multiple service providers or switch providers that act as intermediaries between pharmacies and healthcare transaction claims processors (e.g., pharmacy benefits manager (PBM), an insurer, a Medicare payer, Medicaid payer, accountable care organization, other governmental healthcare insurance payer, or other third-party payer), medication and/or medical product manufacturers, coupon vendors, and the like. These service/switch provider systems can receive healthcare transactions from the pharmacy, via a pharmacy computer, and can pass along the healthcare transaction to the proper claims processor, manufacturer, coupon vendor, etc., via the claims processor computer, for adjudication or other processing. These service/switch provider systems may also provide many services to the pharmacies, claims processors, or manufacturers based on the healthcare transactions that are processed by the particular service/switch provider systems.
In certain situations, one switch/service provider computer may receive a healthcare transaction and may need to transmit it to another switch/service provider computer that is wholly unrelated to the first switch/service provider computer. The exchange of transactions between unrelated switch/service provider computing systems is needed to support the delivery of financial and/or clinical healthcare transactions to payers/claims processor that have an exclusive agreement with one of the switch/service provider systems. For example if a Claims processor A has an exclusive arrangement with Service provider B for the processing of healthcare transactions, but the healthcare transaction is originally transmitted to Service provider A and the healthcare transaction identifies claims processor A as the intended payer destination, Service provider A would transmit the healthcare transaction that is intended for claims processor A to Service provider B. This is done because Service provider A is not authorized to process transactions that are intended for claims processor A.
The exchange of transactions between unrelated switch/service provider computing systems is needed to support the delivery of financial and/or clinical healthcare transactions to hub service business models in which a participating pharmacy wants to access value added services provided by Service provider B but sends its healthcare transactions initially to Service provider A. An example of this situation is when a pharmacy practice management system software vendor or pharmacy chain contracts with Service provider A for hub/switch services and requests sharing of their healthcare transactions with Service Provider B for value-added services.
A problem results in this scenario when Service provider B experiences a network outage or degradation in performance (e.g., the Service provider B computing system is not operating). When this occurs, a participating pharmacy is unable to deliver their financial and/or clinical healthcare transactions to their intended recipients (i.e. claims processors, manufacturers and/or coupon vendors). Without the ability to have its healthcare transactions adjudicated, the pharmacy is not able to provide prescription dispensing services to its customers. This can lead to lost customers or the customers having to come back at a later time when the Service provider B system is hopefully back to an operational state.